Osmotic demyelination syndrome: Difference between revisions

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===Risk Factors===
===Risk Factors===
*Chronic heart failure
*Chronic [[heart failure]]
*Alcoholism
*[[Alcoholism]]
*Cirrhosis
*[[Cirrhosis]]
*Hypokalemia
*[[Hypokalemia]]
*Malnutrition
*[[Malnutrition]]
*Treatment with vasopressin antagonists (e.g. tolvaptan)
*Treatment with vasopressin antagonists (e.g. tolvaptan)
===Risk Factors for Over-correction<ref>George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clinical Journal of the American Society of Nephrology: CJASN, 13(7), 984–992.</ref>===
*Lower initial sodium
*[[Schizophrenia]]
*Lower baseline urine sodium


==Clinical Features==
==Clinical Features==
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*[[Dysarthria]]
*[[Dysarthria]]
*[[Dysphagia]]
*[[Dysphagia]]
*Lethargy
*[[Lethargy]]
*Behavioral disturbances/ confusion
*Behavioral disturbances/ confusion
*Paraparesis or quadriparesis
*[[weakness|Paraparesis]] or quadriparesis
*[[Seizures]]
*[[Seizures]]
*"Locked in" syndrome
*"Locked in" syndrome
*[[Coma]] and [[death]]
*[[Coma]] and [[death]]


==Differential Diagnosis==
==Differential Diagnosis==
 
{{AMS DDX}}


==Evaluation==
==Evaluation==
*MRI can be used to visualize the pontine lesion, with a characteristic "batwing" lesion of the pons appearing in typical cases
*Evaluate for alternative/reversible causes of AMS or exacerbating factors
*[[brain MRI|MRI]] can be used to visualize the pontine lesion, with a characteristic "batwing" lesion of the pons appearing in typical cases


==Management==
==Management<ref>Sterns RH and Hix JK. Overcorrection of hyponatremia is a medical emergency. Kidney International. Volume 76, Issue 6, 2 September 2009, Pages 587-589.</ref>==
In patients with chronic severe hyponatremia (Na <120mEq), the correction rate of sodium should not exceed 6 mEq/24 hours for patients with other ODS risk factors, or 12 mEq/24 hours for those without other risk factors (1).  Hypertonic (3%) saline should be given at a low infusion rate, 0.5 to 1 mL/kg/h, with frequent serum sodium checks to ensure that the correction rate does not exceed the above limits.
*[[Desmopressin]] at 2 mcg q6 hrs IV/SC
*6 mL/kg of 5% dextrose in water, repeated until serum sodium rise back below 9 mEq in 24 hrs


==Disposition==
==Disposition==
*Admit
*Admit
==Prevention==
See [[hyponatremia]] for safe correction rate


==See Also==
==See Also==
 
*[[Hyponatremia]]


==References==
==References==

Revision as of 01:00, 2 October 2019

Background

  • Formerly called "central pontine myelinolysis"
  • A neurologic condition caused by rapid correction of hyponatremia, with starting serum sodium normally 120 meq/L or less
  • Caused by rapid correction of hyponatremia (>12 mEq/L/24 h), as water moves from cells to extracellular fluid, yielding intracellular dehydration.
  • Symptoms are often irreversible or only partially reversible

Risk Factors

Risk Factors for Over-correction[1]

Clinical Features

Symptoms can be present 2-6 days after rapid correction of serum sodium

Differential Diagnosis

Altered mental status

Diffuse brain dysfunction

Primary CNS disease or trauma

Psychiatric

Evaluation

  • Evaluate for alternative/reversible causes of AMS or exacerbating factors
  • MRI can be used to visualize the pontine lesion, with a characteristic "batwing" lesion of the pons appearing in typical cases

Management[2]

  • Desmopressin at 2 mcg q6 hrs IV/SC
  • 6 mL/kg of 5% dextrose in water, repeated until serum sodium rise back below 9 mEq in 24 hrs

Disposition

  • Admit

Prevention

See hyponatremia for safe correction rate

See Also

References

  1. George, J. C., Zafar, W., Bucaloiu, I. D., & Chang, A. R. (2018). Risk Factors and Outcomes of Rapid Correction of Severe Hyponatremia. Clinical Journal of the American Society of Nephrology: CJASN, 13(7), 984–992.
  2. Sterns RH and Hix JK. Overcorrection of hyponatremia is a medical emergency. Kidney International. Volume 76, Issue 6, 2 September 2009, Pages 587-589.